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California Water Labsrc s��� rc� 5r-a��c n. <br /> P 0. Box 4149 Client�'` <br /> 1430 CARPENTER LANE Address PC., ()c c,j >�" ; �, 1C�J� c A <br /> MODESTO CA 95352 3 <br /> PHONE(209)527-AO50 Phone No. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> !' 4T :"1 570ck !6NI <br /> PROJECT NAME: X, <br /> J <br /> SAMPLERS (signature) <br /> Number <br /> REMARKS moo-us <br /> of - <br /> 5tatian <br /> Number nate Time a � Station Location Con- �� � `.�� {� <br /> tainers <br /> 1 <br /> Relinquished bl(signature): Date / Time Received by (signature): Relinquished by(signature) . irate / Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Relinquished by(siynatur�,): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> y+ Company or Agency: (signature) <br />